Distance Education Scholarship for MSW Students Application Form

$1,000 for Fall 2013 Semester

Scholarships are awarded based upon financial need and a student must be formally admitted to the MSW program in Des Moines, Quad Cities, or Sioux City to be eligible. Please complete this form and submit by Friday, October 11, 2013 to:

% Kate Kemp, Program Administrator

University of Iowa, School of Social Work,

308 North Hall

Iowa City, IA 52242

FAX: 319-335-1711 Email:

Section I: Personal & Academic Information

Name: ______

University ID or Social Security #: ______

Street Address: ______

City, State, Zip: ______

Phone: ______(home) ______(work)

Email Address: ______

Country or State of Residence for Tuition Purposes: ______

MSW Admission Status: □ Full-time □ Part-time (less than 9 hours enrollment)

Campus: □ Sioux City □ Quad Cities □ Des Moines

Cumulative GPA: ______

Section II: Financial Information

Cost of educational expenses for the current semester: Fall 2013 (tuition, fees and books): $______

Is your employer paying for any of your educational expenses? □ Yes □ No

If yes, what is the total amount of your employer’s contribution? $______

Will you need to take out a loan for your educational expenses? □ Yes □ No

If yes, what is the total amount you intend to borrow? $______

What is your present indebtedness for educational loans: $ ______

To date, have you been awarded any scholarships, fellowships, and/or stipends from the School of Social Work? □ Yes □ No

If yes, please indicate amount and dates of support: ______

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Section III

Please briefly state how this $1,000 scholarship will help you to achieve your academic goals.

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PLEASE BE ADVISED THAT IF YOU ARE AWARDED A SCHOLARSHIP, IT MAY AFFECT OTHER FINANCIAL AID YOU ARE RECEIVING.

The School of Social Work requests this information for the purpose of evaluating financial need for assistantship appointments. Persons outside the School are not routinely provided this information except for directory information, such as name and local address.